Professional Documents
Culture Documents
Emergency
COntent
cardiac emergency
Contents
Chapter 1: Cardiac emergency:
Acute ST Elevation Myocardial Infarction1 .
Non ST Elevation Myocardial Infarction.
Atrial fibrillation.
Bradydysrhythmias.
Hypertension.
Acute Aortic Syndromes.
Deep Venous Thrombosis.
Chapter 2: Pulmonary emergency:
Acute bronchial Asthma.
Chapter 3 : Neurological emergency:
Headache.
Adult Acute Bacterial Meningitis.
Chapter 4 :Toxicology:
Acetaminophen (Paracetamol, APAP) Overdose.
Carbon Monoxide Poisoning.
Chapter 5 : Hematological emergency:
Sickle cell disease in emergency department.
Anticoagulation Emergencies.
Chapter 6 : Endocrinology and electrolyte emergency:
Hypokalemic and Hyperkalemia Emergencies.
Diabetic emergency.
4
conten t
con t en t
cardiac emergency
Chapter
1
CRADIAC
EMERGENCY
cardiac emergency
2.
3.
cardiac emergency
Clinical Presentation
o History
Chest pain, when it started, what it feels like
(stabbing, crushing, pressure, aching), and if
it radiates to other parts of the body.
Dizziness, nausea.
Shortness of breath.
o Physical Examination
Hemodynamic stability, signs of heart failure/left ventricular dysfunction.
cardiac emergency
Differential diagnosis
o Heart
Acute coronary syndrome
Pericarditis
Myocarditis
Endocarditis
Valvular disease
o Lungs
Pulmonary embolus
Pneumothorax
Pneumonia
Empyema
Hemothorax
COPD
o Esophagus
Esophagitis
GERD
Spasm
Foreign body
Rupture (Boerhaaves)
Esophegeal Tear
o Work up
CBC.
Electrolytes.
Coagulation studies.
Cardiac enzymes.
ECG.
Cardiac biomarkers.
10
cardiac emergency
Management
o Prehospital Care:
Three goals:
(1) Delivering patients to an appropriate health care facility as
quickly as possible.
(2) Preventing sudden death and controlling arrhythmias by using
acute cardiac life support (ACLS) protocol when necessary.
(3) Initiating or continuing management of patients during interfacility transport.
Checklist to get from the EMS team includes the following information:
cardiac emergency
11
12
Do ECG.
cardiac emergency
Unfractionated heparin:
-For patients undergoing primary PCI, we suggest an initial intravenous (IV) bolus of 50 to 70 units/kg up to a maximum of
5000 units.
-For patients treated with fibrinolysis, we suggest an IV bolus of
60 to 100 units/kg up to a maximum of 4000 units and for patients treated with medical therapy (no reperfusion) an IV bolus
cardiac emergency
13
Admit to ICU
High-risk patient:
-Early conservative:
Clopidogrel 300 mg.
14
cardiac emergency
Disposition
Admit to ICU.
o Alert
cardiac emergency
15
Myocardial disease.
Wolff-Parkinson-White syndrome.
Pericardial disease.
16
Thyrotoxicosis.
Hypothermia.
Alcohol use.
Severe infection.
Hypoxia.
Pulmonary emboli.
Pneumonia.
Kidney disease.
Obesity.
Diabetes mellitus.
Digoxin toxicity.
Electrolyte abnormalities.
Clinical Presentation
o History
Anxiety, palpitations, shortness of breath,
dizziness, chest pain, or generalized fatigue.
Physical Examination
Vital signs.
Oxygen saturation.
17
Differential diagnosis
Rhythm
Atrial
Frequency,
beats/min
Ventricular
Frequency,
beats/min
P-wave
Sinus
tachycardia
100-180
100-180
Precedes every
QRS complex
Atrial
fibrillation
400-600
irregu ,60-1900
larly irregular
Absent
Atrial
flutter
250-350
regu ,75-1500
lar, sometimes
alternating
block
Sawtooth
Atrioventricular
nodal
reentrant
tachycardia
180-250
180-250
In QRS complex
)(R
75-250
Precedes QRS;
P-wave differs
from sinus Pwave
100 >
or more dif 3
ferent P-wave
morphologies at
different rates
Atrial
tachycardia
Multifocal atrial
tachycardia
18
120-250
100 >
cardiac emergency
Atrial
fibrillation with
WolffParkinsonWhite
syndrome
400-600
with ,180-300
wide, bizarre
QRS complexes
Absent
Work up
Electrocardiogram.
Metabolic panel.
Coagulation studies.
A thyroid panel.
Chest radiography.
cardiac emergency
19
Management
o Prehospital Care:
Cardioversion considered if the patient exhibits signs
of hemodynamic compromise or poor coronary artery
perfusion.
o In hospital care:
Unstable Patients: as :
-
Hypotension.
200-360 J monophasic.
Anticipate failure.
20
cardiac emergency
o Give: Amiodarone.
If No suspicious of accessory pathway:
Or
cardiac emergency
21
Beta blockers as :
Esmolol 0.5 mg/kg over one min loading dose then 0.06-0.2 mg
/ kg/ min
Metoprolol 2.5 -5 mg bolus over 2 min , up to 3 doses.
o Disposition
22
Admission of new-onset AF only for patients with decompensated heart failure or myocardial ischemia or
for patients who are highly symptomatic and in whom
adequate rate control cannot be achieved.
cardiac emergency
o Alert
ECG abnormalities.
cardiac emergency
23
Bradydysrhythmias
Overview
Categories of Bradydysrhythmias
Bradydysrhythmia
Category
Bradydysrhythmia Type
AV blocks
24
cardiac emergency
Sinus bradycardia
Sinus arrest
Tachy-brady syndrome
Chronotropic incompetence
First-degree AV block
Clinical Presentation
History
Assessing the History of the Patient with Bradydysrhythmia
History
Myocardial ischemia/infarction
Infectious agent
Hypothyroidism
Abdominal pain or
distention
Intra-abdominal hemorrhage
Recent additions or
changes to medications
Drug toxicity
History of end-stage
renal disease, receiving
dialysis
Hyperkalemia
cardiac emergency
25
Physical Examination
o Differential diagnosis
26
cardiac emergency
Category
Disease Process
Ischemia and
infarction
Neurocardiogen
ic or reflex-mediated
Vasovagal reflex
Hypersensitive carotid sinus syndrome
Intra-abdominal hemorrhage
Increased intracranial pressure
Metabolic, en
docrine, and environmental
Hypothyroidism
Infectious and
postinfectious
Hyperkalemia
Hypothermia
Lyme disease (Borrelia species)
Viral agents (parvovirus B19, coxsackievirus B, etc)
Syphilis (Treponema pallidum)
Toxicologic
cardiac emergency
27
Work up
A drug level should be obtained on all patients who are currently taking digoxin.
Cardiac biomarkers.
CT of the head.
Chest x-ray.
Management
o Prehospital Care:
28
IV access.
cardiac emergency
In hospital:
o The Unstable Patient:
Atropine administration remains the first-line medication for unstable and symptomatic patients with
bradydysrhythmias:
-The recommended dose is 0.5 mg intravenously every 3 to 5 minutes, with a maximum dose of 3 mg.
If atropine administration has been ineffective, a betaadrenergic agent (such as dopamine, epinephrine, or
isoproterenol) should be considered.
cardiac emergency
29
Drug or Toxin
Beta blockers
+ 0.5 glucose
Digitalis (di)goxin
Digoxin immune Fab (Digibind or DigiFab): empirically, 10-20 vials (if serum digoxin level is available, product insert can be
)used for more exact dosing guide
Opioids
Organophosphates
30
cardiac emergency
Disposition
Hypertension
Overview
Definitions of Hypertension
Hypertensive emergency
Blood pressure > 140/90 mm Hg with impending or progressive
Target organ dysfunction
Hypertensive urgency
Blood pressure > 180/120 mm Hg without impending or progressive
Target organ dysfunction
Hypertensive crisis
A hypertensive emergency or urgency
Mean arterial pressure
Average blood pressure reading over 1 cardiac cycle; can be
cardiac emergency
31
calculated
As [systolic blood pressure + (2 x diastolic blood pressure)] 3
Essential hypertension
Hypertension without a specific secondary cause
Secondary hypertension
Hypertension related to an underlying pathologic process, e.g.,
adrenal disease; renal disease; or drug effects, interactions, or
withdrawal.
Clinical Presentation
History
Key Questions Regarding History of the Present Illness
Question Comments/Concerns
- Have you ever been told you have high blood pressure?
Open-ended, inclusive question; many people do not think they
have high blood pressure if they are takingor have in the past
takenmedication for it.
- Do you have any chest pain?
Myocardial infarction, aortic dissection
32
cardiac emergency
cardiac emergency
33
Physical Examination
A funduscopic examination.
Differential Diagnosis
34
Stroke.
Aortic dissection.
Renal failure.
Pheochromocytoma or other.
cardiac emergency
Tumor.
Thyroid storm.
Work up
Serum chemistry.
Electrocardiogram.
Chest radiograph.
Urinalysis.
Pregnancy test.
o Management
o Prehospital Care
cardiac emergency
35
In hospital care:
Asymptomatic Patients with BP Less Than 180/110 mm Hg:
-Patients with BP measurements less than 180/110 mm Hg with
no signs of End organ damage ,do not need to be treated in the
ED
-Instead, these patients should follow up with a primary care
provider within 1 week.
Patients with BP Over 180/110 mm Hg and a History Of
Hypertension on Antihypertensive Medications:
-If these patients have missed their medications, they may be
restarted on the drugs.
-Efforts should be made to ensure that the barriers that prevented
the patient from taking the medications are addressed.
-For those patients who are compliant with their medications but
still have an elevated BP, adjustments must be made.
Asymptomatic Patients with BP Over 180/110 mm Hg and No
History of Hypertension:
-In this scenario, patients should be started on antihypertensive
medication ( no need to aggressive lowering of BP ) , and regular follow-up in OPD clinic .
36
cardiac emergency
Dose
Onset of
Action
Duration of
Adverse
Effects
Special
Indications
Nausea,
vomiting,
muscle
twitching,
sweating,
thiocynate
Most
hypertensive
emergencies;
and
cyanide
intoxication. May
caution
with
high
increase
intracranial pressure
intracranial
pressure
or
Action
Vasodilators
Sodium 0.25-10
nitrog/kg/
prusside min as
IV infusion
Immediate
1-2 min
azotemia
cardiac emergency
37
Nicardipine
hydrochloride
5-15
mg/h
IV
5-10 min
( not
in the
MOH
formulary )
15-30
min,
may
Tachycardia,
headache,
flushing,
Most
hypertensive
emerexceed 4
hrs
local phle- gencies
bitis
except
acute
heart
failure;
caution
with
coronary
ischemia
0.1-0.3
g/kg/
min IV
< 5 min
infusion
30 min
Tachycardia,
headache,
nausea,
flushing
Most
hypertensive
emergencies;
caution
with
glaucoma
38
cardiac emergency
Nitroglycerin
5-100
g/min
as IV
2-5 min
5-10
min
Headache,
vomiting,
methemoglobinemia,
infusion
Coronary
ischemia
tolerance
with
prolonged
use
Enalaprilat
( not
in the
MOH
formulary )
1.255
mg
every 6
hrs IV
15-30
min
6-12 hrs
Precipitous fall in
pressure in
high-renin
states;
variable
response
Acute
left
ventricular
failure;
avoid
in
acute
myocardial
infarction
cardiac emergency
39
Hydralazine
hydrochloride
10-20
mg IV
10-20
min IV
1-4 hrs
IV
10-40
mg IM
2030
min IM
4-6 hrs
IM
Tachycardia,
flushing,
headache,
Eclampsia
vomiting,
aggravation of
angina
Adrenergic Inhibitors
Labetalol
hydrochloride
20-80
mg IV
bolus
5-10 min
every
10 min
0.5-2.0
mg/min
IV
infusion
3-6 hrs
Vomiting, scalp
tingling,
bronchoconstriction,
dizziness,
nausea,
heart
block, orthostatic
hypotension
40
cardiac emergency
Most
hypertensive
emergencies
except
acute
heart
failure
Esmolol
hydrochloride
250
500 g/
kg/
1-2 min
10-30
min
min IV
bolus,
then
Hypotension,
nausea,
asthma,
first-degree heart
block,
heart
50100
g/kg/
min by
Aortic
dissection,
perioperative
failure
infusion;
may
repeat
bolus
after 5
min or
increase
infusion to
300 g/
min
Phentolamine
515
mg IV
bolus
1-2 min
10-30
min
Tachycardia,
flushing,
headache
cardiac emergency
Catecholamine
excess
41
Starting
Dose
Maximum
Useful Dosage
Indication
Contraindication
Thiazide
12.5 mg
daily
25 mg daily
Drug of
choice for
Gout, , hypokalemia,
uncomplicated
hypertension1;
hypercalcemia
diuretics
(eg,
hydrochlorothiazide)
works well
with other
agents
ACE
inhibitor
5-10 mg
daily
(eg, fosinopril,
lisinopril)
40 mg daily
Patients
with CHF,
diabetes,
previous
MI with
low ejection
fraction
42
cardiac emergency
Bilateral
renal artery
stenosis; hypovolemia
25-50 mg
daily
100mg daily
Similar
efficacy to
ACE
inhibitors;
used for
Bilateral
renal artery
stenosis; hypovolemia
patients
who cannot
tolerate these
inhibitors
or in addition to
them
cardiac emergency
43
25-50 mg
bid
metoprolol)
200 mg bid
Patients
with coronary
artery
disease;
longterm
management
of CHF;
rate control;
hyperthyroidism
Not a good
monotherapy
for lone
hypertension;
heart block;
bradycardia;
sick sinus
syndrome;
bronchospasm;
acute decompensated
CHF exacerbation
44
cardiac emergency
180-240
mg
360-540 mg
daily
blockers
Daily
(formulation
dependent)
(eg, diltiazem)
Rate
control or
coronary
artery
disease in
patients
who cannot
take
-blockers
Not a good
monotherapy
for lone
hypertension;
long-acting
agents are
safer than
short-acting
agents; heart
block;
bradycardia;
acute
decompensated CHF
exacerbation;
sick sinus
syndrome
0.1 mg
bid
0.3 mg tid
Hypertension
resistant
to other
modalities
regimen
cardiac emergency
45
10 mg 4
qid
(unknown
mechanism of
vasodilation)
100 mg tid
Hypertension associated
with pregnancy;
hypertension associated
with CHF
in African
Americans
resistant to
other
modalities
46
cardiac emergency
Disposition
If the BP is greater than 200/120 mm Hg ,oral antihypertensive therapy should be started. For BP
greater than 180/110, follow-up should occur within 1 week. If prompt follow-up cannot be ensured,
then further consideration for BP treatment or titration of existing BP medications should be given.
cardiac emergency
47
48
cardiac emergency
The proximal aorta is defined as the aorta proximal to the brachiocephalic artery; the descending aorta is defined as the aorta distal
to the left subclavian artery.
49
Clinical Presentation
o History
Time of onset.
Symptoms.
Character of pain.
Radiation of pain.
Medications.
Family history.
Social history.
50
cardiac emergency
Physical Examination
Pulse deficit.
Neurological findings.
Mesenteric ischemia.
Syncope.
Differential diagnosis
Aortic Regurgitation.
Aortic Stenosis.
Cardiac Tamponade.
Cardiogenic Shock.
Cardiomyopathy.
cardiac emergency
51
Cerebrovascular Accident.
Gastrointestinal Bleed.
Hemorrhagic Shock.
Hypovolemic Shock.
Hiatal Hernia.
Hypertensive Urgency.
Mediastinitis.
Myocardial Infarction.
Myocarditis.
Pancreatitis.
Pericarditis.
Pleural Effusion.
Pneumonia.
Pulmonary Embolism.
52
cardiac emergency
o Work up
Ultrasound.
CT.
MRI.
Conventional Aortography/Angiography.
CBC.
Electrolytes.
Coagulation studies.
Cardiac enzymes.
LFTS.
Pancreatic enzymes.
Urinalysis.
ECG.
cardiac emergency
53
Management
o Prehospital Care:
Intravenous access.
Cardiac monitor.
Supplemental oxygen.
In hospital care:
54
cardiac emergency
Esmolol has the advantage of a very short halflife, while labetalol is an alpha- and beta-receptor
antagonist and may be more effective in controlling both heart rate and blood pressure as a single
agent.
cardiac emergency
55
Medication
Dosage
Comments
Labetalol
Alpha 1-, beta 1-,
and beta 2-receptor
blocker
Metoprolol
Beta 1-receptor
blocker
Preferable due
to short half-life
and easy titration; may be preferred inasthma/
COPD
10-20 mg IV push
q10min up to 300
mg maximum;
infusion 0.5-2.0
mg/min
May be used as a
single agent
5 mg IV q5min up No IV infusion
to 15 mg maxi- available
mum
Propranolol
1 mg IV q5 min No IV infusion
up to 0.15 mg/kg available
Beta 1-, beta 2-recep- maximum
tor blocker
Calcium-channel blockers (target heart rate < 60 beats/min)
56
cardiac emergency
Diltiazem
Bolus 0.2-0.25
mg/kg IV, then
infusion 5-15 mg/
.hr
Second-line
for heart rate
control when
beta blockers are
contraindicated
(e.g., cocaine
toxicity, COPD,
or asthma exacerbation)
Verapamil
5-10 mg IV
NA
Vasodilators (give beta blocker first to prevent reflex tachycardia; target SBP 100-120 mm Hg)
Nitroglycerin
Not a first-line
vasodilator
cardiac emergency
57
Disposition
Close monitoring.
Type B aortic dissections may be cared for by either a cardiothoracic surgeon or a vascular surgeon, depending on the
institution.
58
cardiac emergency
When did the pain start? The time line of pain onset is
important; pain that has been present for weeks without
change is unlikely to be acute DVT. This may lead to
suspicion for other conditions, such as ongoing arterial
insufficiency.
59
Have you been immobilized recently, either due to injury/surgery, or for other reasons, such as a lengthy automobile trip?
60
cardiac emergency
Physical Examination
Differential diagnosis
Cellulitis.
Bakers Cyst.
Superficial thrombophlebitis.
cardiac emergency
61
Work up
CBC.
Electrolytes.
Venography.
Duplex ultrasound.
D-Dimer.
Management
o Prehospital Care:
Primarily supportive.
Start heparin if transportation time is prolonged and patient was moderate to high risk.
In hospital care:
62
cardiac emergency
Disposition
Patients who are sent home after a negative duplex ultrasound should have a repeat
ultrasound examination in 5 to 7 days.
cardiac emergency
63
64
Patients who are low-risk, have a negative duplex ultrasound, and a negative (reliable) D-dimer do not require
any further ultrasound examination, unless the concern
for DVT otherwise increases (e.g., worsening symptoms).
cardiac emergency
Chapter
2
PULMONARY
EMERGENCY
cardiac emergency
65
66
Social History.
Comorbidities.
Cardiovascular disease.
Concomitant lung disease.
Chronic psychiatric disease.
Abbreviations: ED, emergency department; ICU, intensive care
unit.
Clinical Presentation
o History
Pulmonary Emergency
67
Physical Examination
68
Diaphoresis.
Pulmonary Emergency
Wheezing.
Differential diagnosis
Adults
Chronic obstructive pulmonary disease
Acute coronary syndromes
Congestive heart failure
Pulmonary embolism
Pneumothorax
Pneumonia
Airway foreign body
Gastroesophageal reflux disease
Vocal cord dysfunction
Cystic fibrosis
Chronic bronchitis
Pulmonary Emergency
69
Sinus disease
Upper respiratory tract infection.
Children
Croup
Viral and bacterial pneumonia
Airway foreign body
Bronchiolitis
Tracheomalacia
Viral upper respiratory tract infection
Work up
70
Management
o Prehospital Care:
Oxygenation monitoring with pulse oximetry,
Inhaled short acting beta agonists by nebulizer or metered-dose inhaler with spacer.
In hospital care:
Mild-Moderate
Severe
FEV1 or PEFR%
>50%
Unable or
<50%
Oxygen
Maintain
SaO2 >90%
Nebulized solution
5 mg q2030 min 3
doses
Salbutamol (ventoline)
MDI with spacer:
Racemic albuterol
(90 mg/puff)
Same but
may be
unable to do
(with supervision)
Pulmonary Emergency
71
Inhaled anticholinergic:
Nebulized
ipratropium solution
Systemic
corticosteroids
Oral (preferred):
4060 mg prednisone or
equivalent
IV (unable to take PO or
absorb):
60125 mg methylprednisolone (or equivalent)
IV magnesium
sulfate (FEV1
<25%)
Not indicated
4060 mg
prednisone
or equivalent
60125 mg
methylprednisolone (or
equivalent)
23 g over
20 min
72
Pulmonary Emergency
Disposition
Good Response
FEV1 or
PEFR%
(predicted/
personal
best)
>70%
Incomplete
Response
>50% but <70%
Poor Response
<50%
Disposition site:
Home
Yes
No, continue
therapy
No,
continue
therapy
Observation
unit
No
Yes, if available
Yes, if
available
and appropriate
Hospital
ward
No
Yes, if appropriate
Critical care
unit
No
No
Yes, if with
respiratory
insufficiency/failure
FEV1, forced expiratory volume in 1 second; PEFR,
peak expiratory flow rate.
Pulmonary Emergency
73
Alert
Psychological problems.
Exacerbation despite adequate dose steroid tablets pre-presentation (current steroid use).
Presentation at night.
Pregnancy.
74
Pulmonary Emergency
Chapter
3
NEUROLOGICAL
EMERGENCY
cardiac emergency
75
Acute Headache
Overview
o Tension-Type Headache
1. At least 10 episodes of headache attacks lasting from 30 minutes to 7 days
2. At least two of the following criteria:
Pressing/tightening (nonpulsatile) quality
Mild or moderate intensity (may inhibit but does not prohibit
activity)
Bilateral location
No aggravation by walking, stairs, or similar routine physical
activity
3. Both of the following:
No nausea or vomiting (anorexia may occur)
Photophobia and phonophobia are absent, or one but not both
are present.
76
NEUROLOGICAL EMERGENCY
77
Conjunctival injection
Lacrimation
Nasal congestion
Rhinorrhea
Forehead and facial sweating
Miosis
Ptosis
Eyelid edema
1.
78
NEUROLOGICAL EMERGENCY
Clinical Presentation
o History
Detailed account of the current headache.
79
The onset.
Location.
Red-Flag Findings
Subarachnoid hemor
rhage
Meningitis
Temporal arteritis
Carbon monoxide
poisoning
Acute glaucoma
80
NEUROLOGICAL EMERGENCY
Intracerebral tumor
Cerebellar infarction
Idiopathic intracranial
hypertension
Pituitary apoplexy
Hypotension, hypoglycemia,
hyponatremia, visual field deficit,
history of pituitary tumor
Pre-eclampsia
Hypertensive encepha
lopathy
Subdural hematoma
Trauma, coagulopathy
Intracerebral hemor
rhage
NEUROLOGICAL EMERGENCY
81
Physical Examination
Neurologic Examination.
Ophthalmologic Examination.
Onset:
Concerning Responses
Provocation:
What makes the pain
better or worse? Position?
Exercise? Straining?
Quality:
82
NEUROLOGICAL EMERGENCY
Radiation:
Does the pain move or
radiate?
Severity:
How long until your
headache reached its
maximum?
Temporal:
Has the pain changed
over time
Associated:
Thunderclap headache
(maximal pain within minutes of onset) is concerning
for secondary pathology
including SAH, venous
sinus thrombosis, or intracranial hemorrhage.
Chronic, progressively
worsening headaches are
concerning for possible
structural mass or lesion.
Associated neurologic
deficits, vision changes,
or fever are concerning
for dangerous secondary
etiology.
NEUROLOGICAL EMERGENCY
83
Possible Cause:
84
NEUROLOGICAL EMERGENCY
Differential diagnosis
Acute glaucoma.
NEUROLOGICAL EMERGENCY
85
Temporal arteritis.
Carbon monoxide.
o Work up
(MRI).
ESR.
Carboxyhemoglobin.
86
NEUROLOGICAL EMERGENCY
Secondary Cause
Noncontrast CT
head
MRI/MRV brain
tumor/mass
Cerebral/dural venous thrombosis, pituitary apoplexy,
hypertensive encephalopathy
Lumbar
puncture
with Meningitis, SAH, idiopathic
cerebrospinal fluid analysis intracranial hypertension
and OP (opening pressure)
Visual acuity with IOP
Acute glaucoma
Erythrocyte sedimentation
rate
Temporal arteritis
Carboxyhemoglobin
Carbon monoxide
NEUROLOGICAL EMERGENCY
87
Management
o Prehospital Care:
Generalized recommendations include the following:
1. Eliciting a basic history.
2. Evaluating mental status.
3. Performing a brief neurologic examination.
NB: If there is any abnormality in the neurologic or mental status
examination or if the patient appears unwell, emergent transport
.should be activated
In the field, the initial approach includes:
Adjusting temperature.
88
NEUROLOGICAL EMERGENCY
In hospital care:
Primary headache:
NSAIDs - first-line therapy for migraine headaches:
For mild pain:
Diphenhydramine 25 mg IV
And
Prochlorperazine 10 mg IV.
Or
Metoclopramide 20 mg IV.
Consider
Dexamethasone 10 mg IV.
NEUROLOGICAL EMERGENCY
89
IV Fluid.
Triptan.
Uncontrolled hypertension.
Prinzmetal angina.
Cardiac arrhythmias.
Primary vasculopathies.
90
NEUROLOGICAL EMERGENCY
2.
NEUROLOGICAL EMERGENCY
91
Dose
AAN Quality
of Evidence
Ibuprofen
mg PO 400-600
Aspirin
mg PO 1000
Naproxen
mg PO 500-825
Ketorolac
mg IV 15-30
Acetaminophen
mg PO 900-1000
Dihydroergotamine
IV
mg IV 0.5-1
Chlorpromazine
mg/kg IV 0.1
B/C
Metoclopramide
mg IV 20
Prochlorperazine
mg IV 10
Sumatriptan SQ
mg SQ 6
Sumatriptan PO
mg PO 100
Opioids
Varies
Dexamethasone
mg PO/IV 6-10
92
NEUROLOGICAL EMERGENCY
Disposition
NEUROLOGICAL EMERGENCY
93
94
Otitis media.
Sinusitis.
Mastoiditis.
Head trauma.
Recent neurosurgery.
Compromised immune system (eg, resulting from human immu nodeficiency virus [HIV], diabetes mellitus,
asplenia, alcoholism, cirrhosis/liver disease, malnutrition, malignancy, cirrhosis/liver disease, malnutrition,
malignancy, and immunosuppressive drug therapy).
NEUROLOGICAL EMERGENCY
Clinical Presentation
Fever
Other Signs/Symptoms
Tripod position with the knees and hips flexed, the back
arched at a lordotic angle, the neck extended, and the
arms brought back to support the thorax.
Rash.
Arthritis.
Differential diagnosis
Encephalitis.
Aseptic meningitis.
Intracranial abscess.
Metabolic encephalopathy.
NEUROLOGICAL EMERGENCY
95
Work up
Computed Tomography.
Lumbar Puncture.
Management
o Prehospital Care:
Standard personal protective
equipment such as facial masks.
96
Pain medication.
NEUROLOGICAL EMERGENCY
In hospital care:
Dexamethasone.
Empirical antimicrobial:
Predisposing Factor
Common Bacterial
Pathogen
Antimicrobial
Therapy
Age 16-50
years
Neisseria meningitidis,
Streptococcus pneumoniae, Haemophilus influenzae (nonimmunized
)patients
Vancomycin plus
a third-generation
cephalosporin
Age > 50
years
Vancomycin plus
a third-generation
cephalosporin and
ampicillin
Immunocompromised
System
Listeria monocytogenes,
aerobic gram-negative
bacilli, Streptococcus
pneumoniae, Neisseria
meningitidis
Vancomycin plus
a third-generation
cephalosporin and
ampicillin
Cerebrospinal Trauma
Staphylococci, aerobic
gram-negative bacilli,
Streptococcus pneumoniae
Vancomycin plus
either a third-generation cephalosporin with anti-pseudomonal coverage
or meropenem
NEUROLOGICAL EMERGENCY
97
Disposition
98
Admission to hospital.
NEUROLOGICAL EMERGENCY
Chapter
4
TOXICOLOGY
cardiac emergency
99
Preclinical injury
phase
Results of
Laboratory
Tests
Manifestations
Normal
Asymptomatic or mild,
nonspecific
symptoms:
nausea,
vomiting,
anorexia,
malaise
Stage 2
24-72 hours
100
Onset of
liver injury
TOXICOLOGY
ALT, h AST,
bilirubin,
PT,
lactate,
phosphate,
creatinine
Stage 3
72-96 hours
Maximal
hepatotoxicity
Stage 4
5-7 days
Recovery
phase
LFTs, ATN,
creatinine,
ammonia
Normalization
Jaundice,
coagulation
defects, hypoglycemia,
renal failure,
encephalopathy, coma,
MSOF
Complete
resolution of
hepatotoxicity
Clinical Presentation
o History
Dose and time of APAP ingestion.
Duration of ingestion.
Concomitant ingestions.
History of trauma.
TOXICOLOGY
101
Coexisting illnesses.
Physical Examination
102
ABCs
Dehydration.
Blood loss.
Pain.
Agitation.
Pupils
TOXICOLOGY
Skin
Differential diagnosis
Ascending cholangitis.
Biliary disease.
Hepatorenal syndrome.
Hypercalcemia.
Pancreatitis.
Perforated viscus.
Reyes syndrome.
103
o Work up
104
In patients who have a toxic APAP level, follow-up serum testing 12 to 24 hours after the first results.
CBC
LFTS
URIN ANALYSIS
Coagulation Studies
Pregnancy Test
Electrocardiography
Management
o Prehospital Care
Amount of APAP ingested and any congestion.
Evidence of trauma.
In hospital care
105
Disposition
106
Carbon monoxide impairs oxygen delivery and peripheral utilization, causing cellular hypoxia.
Clinical Presentation
o History
Questions to ask include:
Where was the patient found, and under what circumstances?
Was there clear evidence of CO exposure?
Was there loss of consciousness?
TOXICOLOGY
107
Cardiac wheezing or crackles in the lungs, signifying myocardial depression secondary to smoke inhalation.
Differential diagnosis
108
Acuterespiratory distresssyndrome.
Alcohol toxicity.
Altitude illness.
Cluster headache.
TOXICOLOGY
Cyanide poisoning.
Depression.
Diabetic ketoacidosis.
Encephalitis.
Gastroenteritis.
Hypoglycaemia.
Hypothyroidism.
Labyrinthitis.
Lactic acidosis.
Meningitis.
Methaemoglobinaemia.
Migraine.
Smoke inhalation.
Tension headache.
Alcohol toxicity.
Narcotic toxicity.
TOXICOLOGY
109
o Work up
Co-oximetry.
Cardiac Biomarkers.
Lactate.
Pregnancy Testing.
Chest x-ray.
Computed Tomography.
ECG.
Management
o Prehospital Care:
110
Recognize the potential for CO poisoning and examination of the scene for evidence of combustion or abnormal odors or fumes.
TOXICOLOGY
o In hospital care:
Signs of end-organ dysfunction and COHb level significantly elevated:
TOXICOLOGY
111
112
Severe headaches.
Dizziness.
Mental Confusion.
Nausea.
Fainting.
Pregnancy.
TOXICOLOGY
Chapter
5
HEMATOLOGICAL
EMERGENCY
cardiac emergency
113
Clinical Presentation
o History
-Pain:
-What complications of SCD have you had?
-Pain - Acute chest syndrome Stroke - Infections - Avascular
necrosis - Priapism Cholecystitis - Splenic sequestration - Renal failure - Pulmonary hypertension - Pulmonary disease - Leg
ulcers - Vision loss
114
Hematological Emergency
Eyes.
115
Differential diagnosis
Common
Rare
Extremely Rare
Vaso-occlusive
crisis
Hepatic sequestration
Infection
Splenic sequestration
Renal infarction
Stroke
Osteomyelitis
Cholelithiasis
Splenic infarction
Priapism
Retinal detachment
Mesenteric
ischemia
o Work up
116
CBC.
L.F.T.
Reticulocyte count.
ALT.
Hematological Emergency
LDH.
o Management
o Prehospital Care
Transport patients who are already being followed by a specific hematology service to that hospital.
o In hospital care
Hematological Emergency
117
Opiate therapy:
Administer IV dose of opiate:
Morphine 0.1-0.15 mg/kg.
Antihistamines
Acetaminophen
118
Uncontrolled pain.
Infections.
Hematological Emergency
Anticoagulation Emergencies
Overview
Target INRs for the anticoagulated Patient:
Indication
2.5 (2.0-3.0)
Atrial fibrillation
2.5 (2.0-3.0)
3.0 (2.5-3.5)
2.5 (2.0-3.0)
Cardiomyopathy
2.5 (2.0-3.0)
2.5 (2.0-3.0)
Hematological Emergency
119
Effect
Sulfonamides21
Fluoroquinolones21,25-27
Doxycycline
Amoxicillin
Antifungals25
Inhibit CYP2C9
Acetaminophen25
Metronidazole
Amiodarone
Inhibits CYP2C9
Clinical Presentation
o History
120
Hematological Emergency
Degree of anticoagulation.
History of medications.
Physical Examination
Pupillary response.
Motor examination.
Sensory examination.
Location of ecchymosis:
Celluens
Periumbelical
Tumers
Flanks
Foxs
Bryants
Scrotum
Hematological Emergency
121
Differential diagnosis
Retroperitoneal hemorrhage.
Hemothorax.
Gastrointestinal bleeding.
Hemopericardium.
Compartment syndrome.
Hematuria.
o Work up
CBC
Chemistry Panel.
Coagulation profile.
Urinalysis.
122
Hematological Emergency
o Imaging
According to presentation and possible complications.
o Management
o Prehospital Care:
All Anticoagulated patients with head injury should be transported to a facility with 24-hour diagnostic imaging, and
there should be a low threshold for transporting to a trauma
center with neurosurgical capabilities.
Universal precautions including gloves, mask, and eye protection or face shield.
Hematological Emergency
123
o In hospital care:
o Management of Supratherapeutic INR:
If serious or life- threatening administer all of the following:
Vitamin K 10 mg IV slowly (Can be repeated every 12 hours).
FFP.
PCC or rFVIIa*.
o If no bleeding:
INR = 3 to < 5
1. Omit next dose
2. Recheck INR frequently.
INR = 5 to < 9
1. Omit next 1 or 2 doses
2. Recheck INR
3. Consider oral vitamin K (1- 2.5 mg) if at increased risk of
bleeding,
124
Hematological Emergency
INR = 9
1. Omit next 1 or 2 doses
2. Administer oral vitamin K (2.55 mg)
3. Recheck INR within 24-48 hours.
* If PCC or rFVIIa is unavailable, proceed with vitamin K and
FFP.
Abbreviations: FFP, fresh frozen plasma; INR, international normalized ratio; PCC, prothrombin complex concentrate; rFVIIa,
recombinant activated factor VII.
Management of Minor Head Injury in the Anticoagulated Patient:
125
126
Hematological Emergency
Chapter
6
ENDOCRINOLOGY AND
ELECTROLYTE EMERGRNCY
cardiac emergency
127
Overview
129
Clinical Presentation
o History
Generalized weakness.
Flaccid paralysis.
Respiratory difficulty.
Gastrointestinal complaints.
Kidney disease.
Endocrine disease.
New medications started in the last year including diuretics, ARBs, ACEIs, diabetes medications, or thyroid
medications.
Recent trauma.
Physical Examination
Organ
System
Cardiac
Hypokalemia
Hyperkalemia
Dysrhythmias
C o n d u c t i o n
defects
Increased likelihood of dysrhythmias due
to digitalis
Dysrhythmias
Conduction
bances
Weakness
Paresthesia
Paralysis
Hyperreflexia
Cramping
Skeletal
muscle
Weakness
Paralysis
Fasciculations
and tetany
Gastrointestinal
Ileus
Nausea
Vomiting
Abdominal
distention
Renal
Polyuria
distur-
Nausea
Vomiting
Diarrhea
131
Differential Diagnosis
Diabetes.
Myocardial infarction.
Stroke.
Viral illnesses.
Myasthenia gravis.
Botulism.
Polyneuropathies.
Cataplexy.
o Work up
ECG.
Urine studies.
Arterial blood gas, serum and urine osmolality, and urine electrolytes.
o Electrocardiogram in Hypokalemia
Flattened T-waves.
ST-segment depression.
U-waves.
o Electrocardiogram in Hyperkalemia
Peaked T-wave.
Flattened P-wave.
Prolonged PR interval.
Absent P-wave.
Wide QRS.
Sine-wave pattern.
133
Management
o Prehospital Care:
In hospital care:
Management of Hypokalemia
Management of Hyperkalemia
135
Commence ACLS
Consider hemodialysis.
Disposition
Hypokalemic patients:
Hyperkalemic patients:
137
Diabetic Emergencies
Overview
Diabetic Ketoacidosis
Hyperglycemic Hyperosmolar
Syndrome
Ketoacidosis
Profound
Minimal or none
Glucose
~250-600 mg/
dL
< 15 mEq/L
> 15 mEq/L
300-325
mOsm
Young
Elderly
Acute; over
hours to days
Associated
diseases
Common
Common
Seizures
Very rare
Common
HCO3
Osmolarity
Age
Onset
Coma
Rare
Common
Insulin
levels
Very low to
none
May be normal
Mortality
0%-10%
20%-40%
(depends on
underlying
conditions)
Dehydration
Severe
Profound
Clinical Presentation
History
Polyuria.
Polydipsia.
Polyphagia.
Weight loss.
Abdominal pain.
Hyperventilation.
139
Sunken eyes.
Febrile.
Work up
CBC.
Full Chemistry.
VBGS.
Serum Glucose.
Serum Ketones.
Serum Osmolality.
Management
Prehospital Care:
Primarily supportive.
141
Intravenous line should be started and normal saline given as a bolus of up to 1 liter in
the average-sized adult.
Diabetic Ketoacidosis
Fluids:
Insulin:
Bicarbonate:
Potassium:
-K > 5.5 mEq/L
Hold K.
Check K every 2 hours.
-K 3.3-5.5 mEq/L
Give 20-30 mEq to keep serum potassium at about 4-5 mEq/L.
143
IV fluidsevery hour.
Disposition
Admit the patient to the ICU if:
hemodynamic instability;
145
Overview
Thyrotoxicosis refers to any state characterized by a clinical
excess of thyroid hormone. Thyroid storm represents the extreme
.presentation of thyrotoxicosis
Myxedema coma is used to describe the severe life-threatening
.manifestations of hypothyroidism
The term myxedema coma itself is a misnomer, as patients do
not usually present with frank coma but more commonly have altered mental status or mental slowing. Myxedema actually refers
to the nonpitting puffy appearance of the skin and soft tissues
.related to hypothyroidism
147
Clinical Presentation
o History
Historical Questions In The Evaluation Of Thyroid Storm
Physical Examination
The patient with thyrotoxicosis classically presents:
Febrile.
Tremulous.
149
Weakness.
Weight loss.
Palpitations.
Skin changes.
Hypothermia.
Nonpitting edema.
Weight gain.
Hypoglycemia.
Hypoxia.
Sepsis.
Encephalitis/meningitis.
Hypertensive encephalopathy.
Alcohol withdrawal.
Benzodiazepine/barbiturate withdrawal.
Opioid withdrawal.
Heat stroke.
Hypoglycemia
Hypoxia
Sepsis
Cerebrovascular accident
Intracranial hemorrhage
Panhypopituitarism
Endocrinology and electrolyte Emergency
151
Adrenal insufficiency
Hyponatremia
Gastrointestinal bleeding
Conversion disorder
o Work up
Full chemistry.
Cardiac markers.
Urinalysis.
Electrocardiogram.
Chest Radiography.
Echocardiography.
Management
o Prehospital Care:
Vital Signs.
153
In hospital care:
o Management of myxedema coma:
Empiric glucocorticoids.
Thyroid Storm:
Three-Step Treatment Of Thyroid Storm
Goal
Treatment
Effect
Step 1
Block
peripheral
effect of
thyroid hormone
Slows heart
rate, increases
diastolic filling,
and decreases
tremor.
Step 2
Stop the
production of
thyroid hormone
Antithyroid
decrease synthesis of thyroid
hormone in the
thyroid.
Propylthiouracyl
slows conversion of T4 to T3
in periphery.
Dexamethasone
decreases conversion of T4 to
T3 in periphery.
Step 3
155
Disposition
Admission must be in ICU department.
Chapter
7
UROLOGICAL
EMERGECY
cardiac emergency
157
Muscle stiffness.
Cramping, swelling.
Tea-colored urine.
Physical Examination
158
Extremity swelling.
Tenderness.
Motor weakness.
Sensory deficits.
UROLOGICAL EMERGRNCY
Differential diagnosis
Seizures, alcohol withdrawal syndrome, strenuous exercise, tetanus, severe dystonia, acute mania.
Heat stroke, malignant hyperthermia, neuroleptic malignant syndrome, serotonin syndrome, hypothermia/
frostbite.
Ethanol, methanol, ethylene glycol, heroin, methadone, barbiturates, cocaine, caffeine, amphetamine,
LSD, MDMA (ecstasy), mushrooms, PCP, benzodiazepines, toluene, etc.
159
160
UROLOGICAL EMERGRNCY
o Work up
Electrolyte evaluation.
Electrocardiogram (ECG).
Management
o Prehospital Care:
Rapid recognition.
UROLOGICAL EMERGRNCY
161
o In hospital care:
CK < 1000
Repeat CK in 8 hours
Recheck CK periodically
CK > 5000
Disposition
.Admission in all cases
162
UROLOGICAL EMERGRNCY
Men
Obstructive Causes
Cystocele
BPH
Tumor
Meatal stenosis
Phimosis/ paraphimosis
Infectious Causes
Operative Causes
Tumor
Infectious Causes
Operative causes
163
Chemical exposure.
164
UROLOGICAL EMERGRNCY
Differential diagnosis
Bladder calculi.
Bladder clots.
Meatal stenosis.
Neurogenic etiologies.
Paraphimosis.
Penile trauma.
Phimosis.
Prostate cancer.
Prostatitis.
Urethral inflammation.
Urethral strictures.
UROLOGICAL EMERGRNCY
165
o Work up
CBC.
Renal ultrasound.
Management
o Prehospital Care
166
Alleviating pain.
Correcting hypovolemia.
UROLOGICAL EMERGRNCY
In hospital care
Disposition
Concomitant infection, significant comorbid illnesses, impaired renal function, neurological deficits, or complications
of catheterization require emergent urological consultation
and admission.
UROLOGICAL EMERGRNCY
167
168
UROLOGICAL EMERGRNCY
Chapter
8
TRAUMA AND
ENVIRONMENTAL
cardiac emergency
169
Primary injury: Induced by mechanical force and occurs at the moment of injury; the 2 main mechanisms
that cause primary injury are contact (eg, an object
striking the head or the brain striking the inside of the
skull) and acceleration-deceleration.
Initial GCS
Mild head
injury
Moderate head
injury
Severe head
injury
14-15
9-13
3-8
% of total
80
10
10
Mortality (%)
<1
10-15
30-50
Good functional
outcome (%)
>90
20-90
<20
170
The most commonly used method for grading the severity of brain
injury is the Glasgow Coma Score (GCS).
Glasgow Coma Score
Eye Opening
(E)
Motor Response
(M)
4=opens
spontaneously 4=disoriented
5=localizes pain
3=opens to
voice
4=withdraws from
pain
2=opens to
pain
1=none
conversation
3=words, incoherent
2=incomprehensible
3=decorticate posturing
sounds
2=decerebrate
1=none
posturing
1=none
Clinical Presentation
o History
AMPLE history:
171
A- Allergies.
M- Medications.
L- Last meal.
Mechanism of injury.
Nausea.
Vomiting.
Visual difficulty.
172
Physical Examination
Neurological examination.
GCS.
Pupillary examination.
Differential diagnosis
Acute Stroke.
Cerebral Aneurysms.
Hydrocephalus.
Prion-Related Diseases.
Subarachnoid Hemorrhage.
Subdural Empyema.
Trauma and Environmental
173
Subdural Hematoma.
Tonic-Clonic Seizures.
o Work up
CBC.
Chemistry profile.
Coagulation profile.
ABG.
Electrocardiogram (ECG).
Non-contrast CT scan.
174
Management
o Prehospital Care
A-B-C-D assessment.
Degree of disability.
GCS.
Oxygen saturation.
Blood glucose.
Supplemental oxygen
175
In hospital care:
Airway.
Breathing.
Fluid Resuscitation.
Intracranial Pressure Monitoring.
Medical Therapy for Increased ICP: mannitol 0.25 mg - 1.0
mg/kg.
Anticonvulsants: phenytoin or fosphenytoin (20 mg/kg or 20
phenytoin equivalents/kg respectively.
Disposition
176
Alert
Persistent headache.
177
Electrical Injuries
Overview
Comparison of High-Voltage and Low-Voltage Electrical Injuries:
Characteristic
Low-Voltage
Injury
High-Voltage
Injury
Voltage, V
1000 V
> 1000 V
Type of Current
Alternating current
Alternating current
Duration of
Contact
Prolonged
Cause of Cardiac
Ventricular fibrillation
Asystole
Arrest
Tetanic
or direct current
Thoracic muscle
tetany or indirect
trauma
Tetanic (if alternating
current); single
(if direct current)
178
Burns
Superficial
Deep
Rhabdomyolysis
Less common
More common
Blunt injury
Occur
Clinical Presentation
o History
Bystanders and Prehospital providers are a good resource regarding the electrical source, the voltage, the
duration of contact, environmental factors at the scene,
and resuscitative measures already provided.
injury that initially appears to have resulted from a lowvoltage source (e.g., a household appliance) may be due
to a high-voltage source
Medical history (especially cardiac problems), medications, allergies, and tetanus immunization status should
also be obtained.
179
Physical Examination
180
Assessment of vision and hearing should include fundoscopic and otoscopic examination.
Characteristic
Cardiac monitoring
NOT required if
ALL IS
the following are true
Cardiac monitoring
is required if ANY
the following are true
of the
Electrocardiogram
Normal
Documented
arrhythmia or
evidence of ischemia
History of
loss of consciousness
No
Yes
Type of injury
Low-voltage ( 1000
)volts
181
Differential Diagnosis
182
Chemical burn.
Ocular burn.
Thermal burn.
Intracranial hemorrhage.
Lightning Injuries.
Respiratory arrest.
Rhabdomyolysis.
Seizures.
Status Epilepticus.
Syncope.
Ventricular Fibrillation.
o Work up
Electrocardiogram.
CBC.
FULL CHEMISTRY.
CK levels.
183
Rationale/Indication
CBC
Electrolytes
Urinalysis
Serum myoglobin
If intra-abdominal injury is
suspected
Coagulation profile
If intra-abdominal injury is
suspected or if surgical course is
projected
184
Management
o Prehospital Care
185
Cutaneous Injuries
Antibiotic dressings, such as mafenide acetate or sulfadiazine silver should be used to cover the wounds.
Mafenide acetate is preferred for localized full-thickness burns because it has better penetration.
Sulfadiazine silver is preferred for extensive burns because it is less likely to cause electrolyte abnormalities.
Tetanus immunization.
186
Myoglobinuria
Disposition
ICU admition.
All patients with a history of loss of consciousness, documented arrhythmias either before or after arrival to the
ED (including cardiac arrest), ECG evidence of ischemia, or who have a sustained a high-voltage electrical
injury should be admitted for additional monitoring.
187
Heat Injuries
Overview
The most serious type of heat related illness is heat stroke.
Heat stroke definition includes:
(1) A core body temperature of more than 105F (40.5C).
(2) Central nervous system dysfunction.
(3) Exposure to heat stress, endogenous or exogenous, and
(4) Exclusions to include CNS infection, sepsis, neuroleptic malignant syndrome or malignant hyperthermia secondary to anesthetic agents.
188
Both
Exertional
Elderly
Drugs
Children
Obesity
Protective clothing
Current febrile
illness
Recent alcohol
consumption
Lack of sleep,
food or water
Social isolation
Confined to bed
Debilitated
Lack of air conditioning
Live on top floor of
a building
Heat Wave
Skin diseases
(i.e. anhydrosis, psoriasis)
Metabolic
conditions
increasing
Chronic mental
illness
heat production
(i.e. thyrotoxicosis)
Cardiopulmonary
disease
Lack of acclimatization
Chronic illness
Prior heat
stroke
Lack of physical
fitness
Lighter skin
pigmentation
Motivation to
push
oneself/warrior
mentality
Reluctance to
report
problems
Previous days
heat exposure
Elevated Heat
Index
Lack of coach or
athlete education
regarding heat
illness.
189
Clinical Presentation
o History
Information must be sought from EMS personnel, witnesses, and family members.
Medications.
Preceding events in order to understand the circumstances of the heat injury, e.g., medical illness or
exertional activities.
Physical Examination
190
Tachycardia.
Hypotension.
Mental status.
Hydration status.
Differential Diagnosis
Delirium Tremens.
Diabetic Ketoacidosis.
Encephalopathy, Hepatic.
Encephalopathy, Uremic.
Hyperthyroidism.
Meningitis.
Tetanus.
Toxicity, Cocaine.
Toxicity, Phencyclidine.
Toxicity, Salicylate.
o Work up
CBC
Serum Chemistries
Trauma and Environmental
191
Chest radiograph
Electrocardiogram (ECG).
Echocardiography.
Some sources include a marked elevation of hepatic transaminases, however this is not universal.
192
Management
o Prehospital Care
Manual fanning.
193
In hospital care:
o Heat stroke:
194
Extracorporeal circuits.
Disposition
195
196
cardiac emergency
Chapter
9
MEDICATIONS LIST
cardiac emergency
197
Antiplatelet drugs:
Code
Item
Dosage
form
Stength
545021160
Tablet
75 mg
100 mg
Tablet
75 mg
(Aspirin); (Enteric
Coated)
543021233
Clopidogrel (Plavix)
Item
Dosage form
Stength
544021055
Nitroglycerin
Sublingual Tablet
0.4-0.6 mg
544021051
Nitroglycerin
Ampule- vial
50 mg
Opioid Analgesic:
Code
Item
Dosage form
Stength
545024051
Morphine
Sulfate
Ampule
10 mg
Fibrinolytic drugs:
198
MEDICATIONS LIST
Code
Item
Dosage form
Stength
543063182
Alteplase
Vial
50 mg
543063183
Reteplase
Set
10 mg
543044250
Streptokinase
Vial
250,000 I.U
543044260
750,000 I.U
Anticoagulants:
Code
Item
Dosage form
Stength
543024210
Heparin
Calcium
Ampoule
5000 I.U
543024201
Heparin
Sodium
Vial
25000I.U/5ml
543024214
Enoxaparin
Prefilled
syringe
8000 I.U
543024208
Dalteparin
Prefilled
syringe
10000 I.U
MEDICATIONS LIST
199
Item
Dosage
form
Stength
544061410
Amiodarone HCL
Tablet
200 mg
544064415
Amiodarone HCL
Ampoule
150 mg
Diltiazem
Vial
25mg/5ml
544031110
Diltiazem HCL
Tablet
60 mg
544031112
Diltiazem HCL
SR
Tablet
90 mg
Bradydysrhythmias
Code
Item
Dosage form
Stength
545064890
Atropine
Sulfate
Ampule
0.4-0.6
mg/1ml
545064892
Atropine
Sulfate
Prefilled syringe
0.1mg/ml
544094610
Dopamine
HCL
Ampoule or Vial
200 mg
544094612
Dopamine
HCL
Premixed bag
800 mg IN
250ml
D5Wmbag
200
MEDICATIONS LIST
544094621
Adrenaline
(Epinephrine)
Prefilled Syringe
1:10000
(100mcg/ml)
10 ml
544094640
Isoprenaline
HCL (Isoproterenol
HCL)
Ampoule
200 mcg/ml
(5 ml)
Item
Dosage form
Stength
547064650
Glucagon
Vial
1 mg
547064655
Glucagon
Prefilled
syringe
1 mg
548024310
Calcium Gluconate
Ampoule
10%
(10ml)
547064580
Human Soluble
Insulin (Regular)
Vial
100I.U/ml
(10ml)
551054365
Digoxin immune
fab
Ampoule
40 mg
551074480
Naloxone
Ampoule
40mcg/2ml
551074470
Naloxone
Ampoule
400 mcg/
ml
545064890
Atropine Sulfate
Ampule
0.4-0.6
mg/1ml
MEDICATIONS LIST
201
545064892
Atropine Sulfate
Prefilled
syringe
0.1mg/ml
551054380
Pralidoxim chloride
Vial
1gm
Hypertension
Code
Item
Dosage
form
Strength
544104770
Sodium nitroprusside
Ampoule or
Vial
50 mg
Nicardipine
hydrochloride
Vial
25mg/10 mL
Fenoldopam
mesylate
Vial
10m/ml
544021051
Nitroglycerin
Ampoule or
Vial
50 mg
Enalaprilat
Vail
1.25 mg / ml
544104730
Hydralazine
hydrochloride
Ampoule
20 mg
544104770
Sodium nitroprusside
Ampoule or
Vial
50 mg
Nicardipine
hydrochloride
Vial
25 mg / 10 ml
202
MEDICATIONS LIST
Fenoldopam
mesylate
Vial
20 mg / 2 ml
544101790
Labetalol hydrochloride
Ampole or
Vial
5mg/ml
100mg/20ml
544054214
Esmolol hydrochloride
Ampoule or
Vial
100 mg
544104750
Phentolamine
Ampoule or
Vial
10 mg
544071450
Hydrochlorothiazide
Tablet
25 mg
544101747
Lisinopril
10 mg
544101746
Enalapril
10 mg
544101740
Captopril
25 mg
544101745
Perindopril
544101738
Fosinopril
10 mg
544101749
Losartan
50 mg
544101750
Valsartan
80 mg
544101757
Irbesartan
544101760
Telmisartan
Tablets
4-5 mg
150 mg
Tablet
80 mg
MEDICATIONS LIST
203
544051207
Metoprolol
50 mg
544051201
Propranolol
10 mg
544051205
Propranolol
544051173
Atenolol
40 mg
Tablet
50 mg
544051171
Atenolol
100 mg
544101795
Labetolol
100 mg
544051172
Carvidolol
6.25 mg
544051206
Bisoprolol
2.5 mg
544051180
Carvidolol
25 mg
544051203
Bisoprolol
5 mg
544051208
Metoprolol
50 mg
544051253
Satolol HCL
80 mg
544031110
Diltiazem
60 mg
544031112
Diltiazem
)(SR
90 mg
Tablet
544031105
544031120
544031125
544031126
Nimodipine
Verapamil
30 mg
Tablet
40 mg
80 mg
Verapamil
120 mg
Verapamil
544101703
Clonidine
Tablet
100 mcg
544101725
Hydralazine
Tablet
25 mg
204
MEDICATIONS LIST
Item
Dosage form
Strength
544054214
Esmolol
Ampoule or
Vial
100 mg
544051208
Metoprolol
Ampoule
5 mg
544101790
Labetalol
Ampoule or
Vial
5 mg/ml
(100mg/20mg)
544021051
Propranolol
Ampoule or
Vial
50 mg
Diltiazem
Vail
1.25 mg / ml
544034130
Verapamil
Ampoule
5 mg
544024051
Nitroglycerin
Ampoule or
Vial
50 mg
Item
Dosage form
Strength
543024210
Heparin Calcium
Ampoule
5000 I.U
543024201
Heparin Sodium
Vial
25000 I.U /
5 ml
543024221
Tinzaparin
Vial
20000 IU
543024219
Tinzaparin
Prefilled
syringe
18000 IU
543024220
Tinzaparin
Prefilled
syringe
14000 IU
MEDICATIONS LIST
205
543024218
Tinzaparin
Prefilled
syringe
10000 IU
543024214
Enoxaparin
Prefilled
syringe
8000 IU
543024204
Deltaparin
Prefilled
syringe
IU 7500
543024217
Tinzaparin
Prefilled
syringe
4500 IU
Enoxaparin
6000 IU
543024216
Enoxaparin
Prefilled
syringe
6000 IU
543024207
Deltaparin
Prefilled
syringe
5000 IU
543024212
Enoxaparin
Prefilled
syringe
2000 IU
543024213
Tinzaparin
Prefilled
syringe
3500 IU
543024211
Deltaparin
Prefilled
syringe
2500 IU
206
MEDICATIONS LIST
Item
Dosage form
Strength
549012030
Albuterol
Nebulization Solution
0.5 % 20 ml /
bottle
549016040
Albuterol
Metered Inhaler
dose inhalations
25000 I.U /
5 ml
549016110
Ipratropium
20000 IU
547051420
Prednisolone
Tablet
5 mg
547051430
547054450
20-25 mg
Methylpredniso547054460
lone
Ampoule Or vial
548024460
Ampoule or vial
IV magnesium
sulfate
40 mg
500 mg
10% (20 ml)
MEDICATIONS LIST
207
Acute Headache
Code
Item
Dosage form
Strength
545021200
Ibuprofen
Tablet
400 mg
545024323
Sumatriptan
Tablet
50 mg100 mg
545031556
Diphenhydramine
HCL
Vial
25 mg
546054420
Metoclopramide
Ampoule
10 mg
547054480
Dexamethasone
Ampoule
8
mg/2ml
545021160
Aspirin
Tablet
75-100
mg
545021252
Naproxen
Tablet
250 mg
545024324
6 mg
Ketorolac
545021100
Acetaminophen
Tablet
500 mg
Aspirin /
acetaminophen /
caffeine
Tablet
545024325
Ergotamine
Tablet
1 mg
Dihydroergotamine
Ampoule
545034510
Chlorpromazine
Ampoule
25 mg
Prochlorperazine
208
MEDICATIONS LIST
Item
Dosage form
Strength
547054480
Dexamethasone
Ampoule
8 mg/2ml
540014370
Vancomycin
HCL
Vial
500 mg
540014250
Cefotaxim
Sodium
Vial
1 gm
540014256
Ceftriaxone
Vial
1 gm
540014248
Cefepim
Vial
1 gm
540014255
2 gm
540014253
Cefixime
Susspension
100 mg/
5 ml
540014135
Ampicillin
Sodium
Vial
500 mg
540014140
1 gm
MEDICATIONS LIST
209
Item
Dosage form
Strength
551051390
Activated
Charcoal
Powder or
suspension
50-100gm/
Container
551054355
Acetylcysteine
Ampoule
200mg/10
ml
543014170
Vitamin K
(Phytomenadione)
Tablet
10 mg
543014150
Vitamin K
(Phytomenadione)
Ampoule
2 mg
543014160
Vitamin K
(Phytomenadione)
Ampoule
10 mg
543034240
Protamine
sulfate
Ampoule
1%
50mg/5ml
210
MEDICATIONS LIST
Item
Dosage form
Strength
545024051
Morphine sulfate
Ampoule
10 mg
Hydromorphone
Ampoule
545031556
Diphenhydramine
Vial
100 mg
545034555
Promethazine
Ampoule
50 mg
545021105
Paracetamol
Vial
1 gm
Anticoagulation Emergencies
Code
Item
Dosage
form
Strength
543014160
Vitamin K (Phytomenadione)
Ampoule
10 mg
543054315
Recombinant factor
VIIa
Vial
1 mg
543054316
Recombinant factor
VIIa
Vial
2 mg
543054317
Recombinant factor
VIIa
Vial
5 mg
MEDICATIONS LIST
211
Item
Dosage form
Strength
548021455
Potassium
chloride
Tablet
600 mg (8
mmol)
548024450
Potassium
chlorid
Ampoule
15% 2mmol/ml
(10ml)
548024462
Magnesium
Sulfate
Ampoule
50% 5 ml
547064580
Vial
100I.U/ml
(10ml)
549012030
Salbutamol
Nebulization
Solution
0.5% 20ml/bottole
548034600
Dextrose
Ampoule or
vial
50% 50 ml
Diabetic Emergencies
Code
Item
Dosage
form
Strength
548024410
Bottle or
bag
0.9% 500
ml
548024413
Piggy bag
0.9% 100
ml
548024412
Piggy bag
0.9% 50
ml
212
MEDICATIONS LIST
547064580
Vial
100I.U/
ml
(10ml)
548024450
Potassium chloride
Ampoule
15%
2mmol/
ml
(10ml)
548024430
Sodium Bicarbonate
Bottle Or
Bag
5% 250
ml
548024435
Sodium Bicarbonate
Prefilled
syringe
8.4%
1mEq/ml
10 ml
548024420
Sodium Bicarbonate
Prefilled
syringe
8.4%
1mEq/ml
50 ml
Sodium Phosphate
548024310
Calcium Gluconate
Ampoule
10%
10ml
548024462
Magnesium Sulfate
Ampoule
50% 5 ml
MEDICATIONS LIST
213
Item
Dosage
form
Strength
547071715
Levothyroxin
sodium
Ampoule
200-500 mcg
547054405
Hydrocortisone
Ampoule or
Vial
100 mg
544051205
Propranolol
Tablet
40 mg
544051201
Propranolol
Tablet
10 mg
544054210
Propranolol
Ampoule
1 mg
547051470
Dexamethasone
Ampoule
5 mg
547071750
Propylthiouracil
Tablets
50 mg
547071760
Carbimazole
Tablets
5 mg
192000055
131 l-Iodine
therapy dose
50mci
Vial
50 mci
214
MEDICATIONS LIST
Code
Item
Dosage form
Strength
548024410
Bottle or bag
0.9% 500 ml
548024413
Piggy bag
0.9% 100 ml
548024412
Piggy bag
0.9% 50 ml
Item
Dosage form
Strength
547011025
Finasteride
Tablet
5 mg
MEDICATIONS LIST
215
Item
Dosage form
Strength
544074535
Mannitol
Infusion bottle
20% 250 ml
glass bottole
545051748
Phenytoin
Sodium
Capsule
50 mg
545051750
Phenytoin
Sodium
Capsule
100 mg
545051760
Phenytoin
Sodium
Vial
250 mg
216
MEDICATIONS LIST
Refrences
Tintinallis Emergency Medicine (Emergency Medicine (Tintinalli))by David Cline, O. John Ma, Rita Cydulka and Garth Meckler.
MEDICATIONS LIST
217
Authors
Hattan Muhammad Bojan
Consultant Emergency Medicine
Director of Emergency Medical Services Makkah Region
General Directorate of Health Affairs Makkah Region
Makkah, Saudi Arabia
Abdul-Aziz Al-Shotairy
Consultant Emergency Medicine
Director of King Saud Hospital
Ministry of Health
Jeddah, Saudi Arabia
Ayman Yousif Altirmizi
Specialist Mass Gathering Medicine
Primary Health Care
Ministry of Health
Makkah, Saudi Arabia
Suhail Abdullah Khabeer
Clinical Pharmacist
King Saud Hospital
Ministry of Health
Jeddah, Saudi Arabia
218
Illustrations
Medication Table by Suhail Abdullah Khabeer
Reviewed by:
Dr. Sattam AlEnezi, MD, SBEM, ArEM, JBEM, IEM
Consultant Emergency Medicine
Director of Emergency Medicine Departments, MOH
It is with great pleasure that we extend our sincere thanks and
appreciation to Dr Mohammed Okashah for his generous support
and help on this work.
219
M.O.H
DRUG LIST
ALPHAPITICAL
DRUG INDEX
atracurium besylate
atropine sulphate
acetazolam ide
azathioprine
acetylcholine chloride
azelaic acid
azithromycin
)B(
acitren
acyclovir
adalimumab
adefovir dipivoxil
baclofen
adenosine
basiliximab
adrenaline hcl
)adrenaline (epinephrine
beclomethasone
albendazole
bnzhexol hcl
albumen human
benzoyl peroxide
alemtuzumab
benztropine mesylate
alendronate sodium
beractant,phospholipid
alfacalcidol
betahistine dihydrochloride
allopurinol
betamethasone
alprazolam
betaxolol hcl
bevacizumab
alteplase
bicalutamide
bimatoprost
222
bisacodyl
amethocain
bisoprolol fumarate
amikacin sulfate
bleomycin
bortezomib
bosentan
aminocaproic acid
aminoglutethimide
bretulium tosylate
aminophyline
brimonidine tartrate
amiodarone hcl
brinzolamide
bromocriptine
ammonium chlorhde
b-sitosterol
amobarbitol
budesonide
amoxicilline trihydrate
budesonide turbuhaler
amphotericin b liposomal
Bulk-forming laxative
mpicilline sodium
bupivacaine hcl
anagrelide
buprenorphine
anastrozole
bupropion
busulfan
)C(
cabergoline
)antithymocyte globulin(atg
calcipotriol
apracloidine hcl
aripiprazole
)calcitonin (salmon)-(salcatonin
223
calcitriol
artemisinin
calcium carbonate
artesunate
calcium chloride
calcium gluconate
calcium lactate
capecitabine
)sparaginase (crisantaspase
capreomycine
atazanavir
captopril
atenolol
carbamazepine
atorvastatin
carbimazole
carboplatin
cyclophosphamide
carboprost tromethamine
cycloserine
carboxymethyl-cellulose
cyclosporine
carmustine
carteolol hcl
carvedilol
caspofungin acetate
dabigatran
cafaclor
dacarbazine
cefepime hydrochloride
dactinomycin
cefixime
dalteparin
cefixime sodium
danazol
ceftazidime pentahydrate
dantrolene sodium
ceftriaxone sodium
dapsone
224
darunavir
celecoxib
dasatinib monohydrate
cephalexin monohydrate
daunorubicin hcl
cephradine
desmopressin acetate
cetuximab
dexamethasone
chloral hydrate
chlorambcil
dextromethorphan
chloramphenicol
dextrose
chlordiazepoxide hcl
diazepam
chlorhexidine gluconate
diazoxide
chloroquine
diclofenac
chlorpheniramine maleate
didanosine
chlorpromazine hcl
diethylcarbamazine citrate
chlorthalidone
digoxin
chlorzoxazone
)cholecalciferol (vitamine d3
diloxanide furoate
cholestyramine
cincalcet hydrochloride
dimenhydrinate
cinnararizine
dinoprostone
ciprofloxacin
diphenhydramine hcl
cispltin
)diphetheria,tetanus,pertussis (dpt
citalopam hydrobromide
clarithromycin
clindamycin
diphetheria antitoxine
225
dipyridamol
clindamycin phosphate
disodium pamidronate
clofazimin
disopyramide phosphate
clomiphene citrate
distigmine bromide
clomipramine hcl
dodutamine hcl
clonazepam
docetaxel
clonidine hcl
docusate sodium
clopidogral
domperidone
clotrimazole
dopamine hcl
dorzolamide&1
clozapine
doxorubicin
codeine phosphate
duloxetine
colchicine
dydrogesterone
)E(
econazole
corticorelin (corticotrophin-releasing
)factor,crf
edrophonium chloride
cromoglycate sodium
efavirenz
cyclopentolate hcl
emtricitabine
cyclophosphamide
carboplatin
cycloserine
carboprost tromethamine
cyclosporine
carboxymethyl-cellulose
carmustine
carteolol hcl
226
carvedilol
dabigatran
caspofungin acetate
dacarbazine
cafaclor
dactinomycin
cefepime hydrochloride
dalteparin
cefixime
danazol
cefixime sodium
dantrolene sodium
ceftazidime pentahydrate
dapsone
ceftriaxone sodium
darunavir
cefuroxime
dasatinib monohydrate
celecoxib
daunorubicin hcl
cephalexin monohydrate
desmopressin acetate
cephradine
dexamethasone
cetuximab
chloral hydrate
dextromethorphan
chlorambcil
dextrose
chloramphenicol
diazepam
chlordiazepoxide hcl
diazoxide
chlorhexidine gluconate
diclofenac
chloroquine
didanosine
chlorpheniramine maleate
diethylcarbamazine citrate
chlorpromazine hcl
digoxin
chlorthalidone
chlorzoxazone
227
cholestyramine
dimenhydrinate
cincalcet hydrochloride
dinoprostone
cinnararizine
diphenhydramine hcl
ciprofloxacin
diphetheria,tetanus,pertussis (dpt)
cispltin
citalopam hydrobromide
clarithromycin
diphetheria antitoxine
clindamycin
dipyridamol
disodium pamidronate
clindamycin phosphate
disopyramide phosphate
clofazimin
distigmine bromide
clomiphene citrate
dodutamine hcl
clomipramine hcl
docetaxel
clonazepam
docusate sodium
clonidine hcl
domperidone
clopidogral
dopamine hcl
clotrimazole
dorzolamide&1
doxorubicin
clozapine
duloxetine
codeine phosphate
dydrogesterone
colchicine
(E)
econazole
228
corticorelin
factor,crf)
efavirenz
cromoglycate sodium
emtricitabine
cyclopentolate hcl
enalapril malate
Gemfibrozil
enfuvirtide
gentamicine
enoxaparin
glibenclamide
entecvir
gliclazide
ephedrine hydrochloride
glipizide
epirubicin hcl
glucagon
(corticotrophin-releasing
glycrine
ergotamine tartarate
glycopyrrolate bromide
erlotinib hydrochloride
erythromycin
goserlin acetate
escitalopram
granisetron
esmolol hcl
griseofulvin micronized
)H(
estradiol valerate
etanercept
haloperidol
ethambutol hcl
ethanolamine oleate
ethinyl estradiol
ethionamide
homatropine
ALPHAPITICAL DRUG INDEX
229
etomidate
human fibrinogen
etoposide
etravirine
)F(
fat emulsion
hyaluronidase
hydralazine hcimesilate
fentanyl citrate
hydrochlorothiazide
ferrous salt
hydrocortisone
hydroxurea
filgrastim g-csf
hydroxychloroquine sulphate
finasteride
ydroxyprogesterone hexanoate
fluconazole
hydroxypropyl methylcelulose
fludarabine phoaphate
hyocine butylbromide
fludrocortisones acetate
)I(
flumazenil
ibuprofen
fluorescein
ifosfamide
fluorometholone
iloprost
fluorouracil
imatinib mesilate
230
imidazole derivative
flupenthixol
imipenem + cilastatin
fluphenazine decanoate
imipramine hcl
flutamide
fluticasone
indinavir
fluvoxamine malate
indomethacin
follitropin
infliximab
foscarnet
fosinopril
insulin aspart
furosemide
nsulin detmir
fusidic acid
insulin glargine
)G(
insulin lispro
gabapentine
interferon alpha
ganciclovir
interferon beta 1a
gemcitabine
ipratropium bromide
medroxyprogesterone acetate
irbesartan
mefenemic acid
irintecan hydrochloride
melfloquine hcl
iron saccharate
megestrol acetate
isoniazid
meloxicam
melphalan
isosorbide dinitrate
memantine hcl
isosorbide dinitrate
231
isotretinoin
mercaptopurine
itraconazole
meropenem
ivabradine
mesalazine
ivermectin
(K)
mesna
metformin hcl
kanamycin
methadone hcl
kaolin + pectin
methotrexate
ketamine hcl
methoxsalen + ammidine
ketoconazole
ketotifen
(L)
methyldopa
methylerrgonovine maleate
labetalol hcl
methylphenidate
lactulose
methylperdnisolone
lamivudine
metoclopramide hcl
lamotrigine
metolazone tartrate
lansoprazole
metolazone
latanoprost
metolazone tartrate
l-carnitine
etronidazole
leflunomide
mexiletine hcl
lenalidomide
micafungin sodium
letrozole
miconazole
Leucovorin calcium
midazolam
miltefosine
levamizole
232
levetiracetam
mirtazapine
levofaoxacin
misoprostol
levothyroxine sodium
mitomycin
mitoxantrone hydrochloride
Lidocaine hcl
linezolid
moclopemide
liquid paraffin
mometasone furoate
lisinopril
montelukast sodium
lithium carbonate
orphine sulphate
lomustine
moxifloxacin hydrochloride
Loperamide hcl
lopinavir + ritonavir
multivitamins
lorazepam
mupirocin
losartan potassium
muromonab-cd3
lubricant
mycophenolate mofetil
(N)
(M)
magnesium oxide
nafarelin
mannitol
nalbuphine hcl
maprotilline hcl
naloxone hcl
measles vaccine
naphazoline
mebendazole
Naproxene
mebeverine hcl
natalizumab
mechlorethamine hcl
natamycin
meclozine + vitamine B6
ALPHAPITICAL DRUG INDEX
233
nateglinide
phenytoin sodium
nelfinavir
phosphate enema
neomycin sulphate
phosphate salt
neostigmine methylsulpfate
phytomenadione
niclosamide
pilocarpine
pioglitazone
piperacillin + tazobactam
nilotinib
nimodipine
nitrazepam
nitrofurantoin
polyacrylic acid
nitroglycerin
polyethylene glycol,3350-13.125g
oral ppowder, sodium bicarbonate
178.5mg,sodium chloride350mg ,
potassium chloride 46.6mg/sachet
isosorbide dinitrate
potassium salt
norethisterone
pramipexole
norfloxacin
pravastatin
nystatin
praziquantel
(O)
prazosin hcl
octreotide
prednisolone
ofloxacin
234
Prilocaine + felypressin
olanzapine
Primaquine phosphate
olopatadine hcl
Primidone
omeprazole sodium
Procainamide hcl
ondansetron
Procarbazine
orienograstim (g-csf)
Procyclidine hydrochloride
oxaliplatin
Progesterone
oxybuprocaine
Proguanil hcl
oxybutynin hcl xl
Promethazine hcl
oxymetazoline
proparacaine
oxytocin
propfol
(P)
propylthiouracil
paclitaxel
Propranolol hcl
paliperidone
Protamine sulfate
palivizumab
prothionmide
pancuronium bromide
Protirelin (thyrotrpphin-releasing
hormone,trh)
papaverin
Pumactant phospholipid
paracetamol
Pyrazinamide
pegaspargase
Pyrethrins
Pyridostigmine
pemetrexed
penicillamine
235
Prilocaine + felypressin
pentamidine isethionate
primaquine phosphate
pentavalent vacc.(hbv+hib+dtp)
(Q)
pentoxifylline
quetiapine
perindopril
quinidine sulfate
permethrin
quinine dihydrochloride
pethidine hcl
quinie sulphate
phenobarbital (phenobarbitone)
(R)
phentolamine mesylate
streptokinase
racemic epinphrine
streptomycin sulfate
raltegravir
strontium ranelate
ranitidine
succinylcholine choloride
rasburicase
sucralfate
sulfacetamide
repaglinide
sulfadiazine
reteplase
sulfadoxin500mg + pyrimethamine25mg
retinoin (vitamine a)
sulfasalazine,500mg/tablet
ribavirin
sulindac
rifabutine
sulpiride
rifampicin
sumatriptan succinate
riluzole
236
tacrolimus
risperidone
tamoxifen citrate
ritonavir
rituximab
telmisartan
rivaroxaban
temazepam
rocuronium bromide
ropivacaine hcl
terbinafine
rose bengal
teriparatide
rosuvastatin
terlipressin acetate
(S)
tetanus antitoxin
salbutamol
tetanus vaccine
tetracosactrin (corticotrophin)
selegiline hcl
tetracycline hcl
senna
thalidomide
sevelamer
theophylline
sevoflurance
thiacetazone
sildenafil
thioguanine
simethicone
thiopental sodium
simvastatin
tigecycline
sirolimus
timolol
sitagliptin phosphate
tinzaparin sodium
snake anti-venin
237
sodium acetate
tirofiban hydrochloride
sodium aurothiomalate
tobramycin + dexamethasone
sodium bicarbonate
tobramycin sulfate
sodium chloride
tolterodine tartrate
sodium cormoglycate
topiramate
sodium hyaluronate
tramadol hcl
sodium nitropruprusside
tranexamic acid
sodium phosphate
trastuzumab
sodium valpproate
trazodone
tretinoin
sorafenib
triamcinoloneacetonide
sotalol hydrochloride
triamterene + hydrochlorthiazide
spectinomycin hcl
trifluperazine hcl
spiramycin
trifluridine
spironolactone
trimethoprim + sulfamethoxazole
verapamil hcl
triptorelin acetate
tropicamide
vigabatrin
vinblastine sulfate
238
(W)
(U)
warfarin sodium
urea
urofollitrophine f.s.h
wax removal
ursodeoxycholic acid
(V)
(X)
xylometazoline hcl
valaciclovir hcl
(Y)
valganciclover hcl
valsartan
(Z)
vancomycin hcl
zidovudine (azidothymidine,AZT)
zidovudine + lamivudine
vasopressine
zinc sulfate
vecuronium bromide
zolledronic acid
zolpedem tartrate
vincristine sulfate
zuclopenthixol acetate
vinorelbine
vitamine B1 & B6& B12
vitamine B complex
vitamine E
voriconazole
239
Authors
Khalid O. Dhafar, MD, MBA, FRCS, FACS
Consultant General Surgery
Health Affair, Ministry of Health
Jeddah, Saudi Arabia
Hassan Adnan Bukhari, MD, FRCSC
Assistant Professor, General Surgery, Umm Al-Qura University
Consultant General Surgery, Trauma Surgery and Critical Care, King
Abdulaziz Hospital, Makkah, Saudi Arabia
Head of Accident and Emergency Department, Al-Noor Specialist
Hospital
Makkah, Saudi Arabia
Abdullah Mosleh Alkhuzaie, MD, SBGS
Consultant General Surgery
King Abdulaziz Hospital
Ministry of Health
Makkah, Saudi Arabia
Saad A. Al Awwad, MD, SBGS, JBGS
Consultant General Surgery
King Fahad General Hospital, Ministry of Health
Jeddah, Saudi Arabia
240
Illustration
Flowchart by Hassan Adnan Bukhari
Medication Table by Faisal Ahmed Al-Wdani
241
Acknowledgement
Great appreciation for Dr. Ghiath Al Sayed , Consultant General
Surgery,King Fahad medical city, for reviewing and editing this
book.